📋
Extracted from Consolidated Report
This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.
Santa Cruz County Grand Jury
• 2013-2014
To the citizens and employees of Santa Cruz County, The Santa Cruz County Civil Grand Jury, made up of nineteen of your
⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings 15 findings
F1
County medical staff in 2012 at the Main Jail did not follow accepted standards of care in treating an inmate with complications arising from intravenous opiate abuse.
F2
There was inadequate communication between Dominican Hospital and the Main Jail medical staff regarding a critical change in diagnostic information.
F3
CFMG’s current procedures may fail to detect diagnostic updates by Dominican Hospital under certain situations.
F4
CFMG staff failed to identify and treat symptoms of methadone overdose.
F5
CFMG staff at the Main Jail has insufficient oversight and treatment facilities for inmates confined in ‘O’ Unit.
F6
Corrections Bureau and CFMG policies differ over when to call CFMG staff for intake screening of inebriated individuals at the Main Jail.
F7
Corrections Bureau staff at the Main Jail made incorrect judgements regarding the use of monitored housing for inebriated or impaired individuals.
F8
The availability of CIT staff is not adequate for the proper determination of an inmate’s needs for immediate mental health medication and monitoring during intake at the Main Jail.
F9
During the period covered by our investigations, CIT had inadequately documented procedures and lax medical record keeping for the mental health care of inmates at the Main Jail.
F10
Corrections Bureau regulations for the frequency of cell inspections and the enforcement of rules governing items permitted in cells have not been consistently followed by Corrections Bureau staff at the Main Jail.
F11
During the period covered by our investigations, Corrections Bureau protocols and screening practices for individuals entering the Main Jail were insufficient for the interception of illegal drugs.
F12
CFMG has an extensive catalog of best practices based on decades of experience that are detailed in CFMG protocol manuals and maintained through regular training, review, and audits.
F13
The addition of a Compliance Officer to the Corrections Bureau staff, and a new regime of accountability, should result in an improvement in regulation compliance and enforcement at the Main Jail.
F14
CIT record keeping procedures and treatment protocols are undergoing a much needed process of review and improvement.
F15
CIT has established an improved protocol for gradually transitioning inmates under mental health watch in ‘O’ Unit back into the general population.
Recommendations 5
-
R11City on a Hill Press. 2013. “Living Without Prison Bars.” April 11. Accessed 2/11/14. http://www.cityonahillpress.com/2013/04/11/livingwithoutprisonbars/
-
R12Noonan, Margaret E., BJS Statistician and Scott Ginder. 2013. Bureau of Justice Statistics. NCJ 242186. “Mortality in Local Jails and State Prisons, 20002011 Statistical Tables.” Accessed 3/14/14. http://www.bjs.gov/content/pub/pdf/mljsp0011.pdf
-
R13Santa Cruz County Sheriff Coroner. 2012. Annual Report 2012. p. 11. Accessed 3/12/14. http://www.scsheriff.com/Portals/1/County/sheriff/SCSD_Report_2011.pdf
-
R14SheriffCoroner Santa Cruz County. 2012. Death Investigation Report, Case #1207268.
-
R15SheriffCoroner Santa Cruz County. 2012. Death Investigation Report, Case #1208568.
Commendations 5
-
CM1C1. We commend the CFMG staff and management for its high degree of dedication and professionalism. (F12) C2. We commend the Corrections Bureau for its addition of a new Compliance Officer. (F13) C3. We commend CIT management and staff for its efforts to improve and fully document its reporting and procedural protocols. (F14, F15)
-
CM2C1. We commend the Sheriff’s Office for evaluating the feasibility of using video conferencing for routine court appearances to reduce the need for CO escorts. C2. We commend the Sheriff’s Office for its plan to expand and improve the Rountree Facility to help alleviate overcrowded conditions at the Main Jail. C3. We commend the Main Jail kitchen staff for their well managed food service program.
-
CM3The Santa Cruz County Grand Jury would like to commend the Juvenile Hall administrators and staff (particularly the cooks) for their dedication to our County’s young people. The three main cooks have over 30 years experience in the kitchen, and the many anecdotes not mentioned in this investigative report make it clear that they do not take their jobs, or the lives of the residents, for granted. The comment by the staff person who said “Good food equals love, concern, and support” echoed the sentiments of all the Juvenile Hall staff with whom we spoke.
-
CM4C1. The Grand Jury commends HSA for working to provide services in the face of changing requirements, multiyear budget cuts, and evolving mental health treatment and prevention practices. C2. The Grand Jury commends the MHCAN peerled respite center for its success in helping clients avoid crises and support each other to help maintain good mental health.
-
CM5C1. We commend SqCWD for holding board meetings at Capitola City Hall to address supplemental supply and mandatory rationing. This allows for greater public participation and awareness of the discussions via local access television and the internet.